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Question 1 Which of the following statements regarding ingested foreign bodies is correct? a)All children with suspected foreign body ingestion should undergo x-ray. b)Ipecac can be used safely to dislodge a button battery in the esophagus. c)Meat tenderizer can be used safely to dissolve an impacted meat bolus. d)Most common site of esophageal foreign body entrapment in pediatric patients is the thoracic inlet. e)Objects longer than 5cm and wider than 2cm should be removed before they pass through the stomach.

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Q 1 Answer Which of the following statements regarding ingested foreign bodies is correct? a)All children with suspected foreign body ingestion should undergo x-ray. b)Ipecac can be used safely to dislodge a button battery in the esophagus. c)Meat tenderizer can be used safely to dissolve an impacted meat bolus. d)Most common site of esophageal foreign body entrapment in pediatric patients is the thoracic inlet. e)Objects longer than 5cm and wider than 2cm should be removed before they pass through the stomach. PEER VII Q20

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Varicella-Zoster Virus Multiple states of rash on same body part Low-grade fever, malaise, and headache Treatment is symptomatic –Varicella-zoster immune globulin and acyclovir for immunocompromised children

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Question 3 A mother brings her 14 month old son into the ED. For the past 4 to 5 days she has seen mucus in his diapers, and that morning she noted a red mass protruding from his rectum. Regarding this condition, which of the following is correct? a)Affects girls more than boys b)Is associated with cystic fibrosis and malnutrition c)Requires excision of the lesion in the emergency department d)Requires proctasigmoidoscopy e)Requires referral for surgical correction

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Q 3 Answer A mother brings her 14 month old son into the ED. For the past 4 to 5 days she has seen mucus in his diapers, and that morning she noted a red mass protruding from his rectum. Regarding this condition, which of the following is correct? a)Affects girls more than boys b)Is associated with cystic fibrosis and malnutrition c)Requires excision of the lesion in the emergency department d)Requires proctasigmoidoscopy e)Requires referral for surgical correction PEER VII Q334

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Rectal Prolapse Affects very young and very old Loose connection of mucosa to submucosa Laxity of anal sphincter Mucus or Blood-stained mucus in diaper Protruding mass after bowel movement Associated with cystic fibrosis Reducible in ED with sedation as needed

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Question 4 For previously healthy children with community-acquired pneumonia, which of the following statement is correct? a. Age is the most important factor in selecting empiric antibiotic therapy b. Concurrent presence of watery diarrhea reliably identifies a viral etiology c. Localized chest pain is the most commonly associated with viral pneumonia d. Viral and bacterial pneumonias can reliably be differentiated in infants e. Wheezing in preschool-aged children is pathognomonic for viral pneumonia

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Q 4 Answer For previously healthy children with community-acquired pneumonia, which of the following statement is correct? a. Age is the most important factor in selecting empiric antibiotic therapy b. Concurrent presence of watery diarrhea reliably identifies a viral etiology c. Localized chest pain is the most commonly associated with viral pneumonia d. Viral and bacterial pneumonias can reliably be differentiated in infants e. Wheezing in preschool-aged children is pathognomonic for viral pneumonia PEER VII Q343

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Question 5 For a previously healthy toddler with mild croup, the administration of oral dexamethasone: a)Is indicated only for moderate-to-sever croup, because mild croup is self- limited. b)Is indicated only if the parents are unable to provide cool mist at home c)Is precluded by an unacceptably high rate of uncontrollable vomiting after administration d)Leads to mild hyperactivity that interferes with normal sleep patterns e)Leads to quicker resolution of symptoms when compared with observation

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Q 5 Answer For a previously healthy toddler with mild croup, the administration of oral dexamethasone: a)Is indicated only for moderate-to-sever croup, because mild croup is self- limited. b)Is indicated only if the parents are unable to provide cool mist at home c)Is precluded by an unacceptably high rate of uncontrollable vomiting after administration d)Leads to mild hyperactivity that interferes with normal sleep patterns e)Leads to quicker resolution of symptoms when compared with observation PEER VII Q347

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Question 7 A 9 month old boy presents with hypotonia and constipation. His mother says he has recently started eating “table food.” Which of the following is the most likely diagnosis? a. Botulism b. Ciguatera c. Listeriosis d. Scombroid poisoning e. Typhoid

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Q 7 Answer A 9 month old boy presents with hypotonia and constipation. His mother says he has recently started eating “table food.” Which of the following is the most likely diagnosis? a)Botulism b)Ciguatera c)Listeriosis d)Scombroid poisoning e)Typhoid PEER VII Q349

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Question 8 Which of the following statements regarding intussusception is correct? a)If the stool is negative for occult blood, the diagnosis is excluded. b)Most patients show profound dehydration at the time of diagnosis c)Mucus-laden, bloody, “currant jelly” stools are seen in most cases d)Postreduction recurrence is best predicted by patient age and sex e)Ultrasonography is an accepted diagnostic test

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Q 8 Answer Which of the following statements regarding intussusception is correct? a)If the stool is negative for occult blood, the diagnosis is excluded. b)Most patients show profound dehydration at the time of diagnosis c)Mucus-laden, bloody, “currant jelly” stools are seen in most cases d)Postreduction recurrence is best predicted by patient age and sex e)Ultrasonography is an accepted diagnostic test PEER VII Q354

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Intussusception Telescoping of one portion of the intestine into another –Most commonly occurs between the ileum and colon Most prevalent 3 months to 6 years old Presentation –Sudden abdominal pain –Pain-free intervals –Sausage-shaped mass on R Diagnosis –US used for diagnosis Treatment –Barium or Air enema diagnostic and therapeutic –Possible Surgical Correction

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Question 9 For young infants who are vomiting, which of the following is most likely to differentiate acute malrotation with midgut volvulus from pyloric stenosis? a)Abdominal examination b)Color of the vomitus c)History of constipation d)Presence of high fever e)Resting tachycardia

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Q 9 Answer For young infants who are vomiting, which of the following is most likely to differentiate acute malrotation with midgut volvulus from pyloric stenosis? a. Abdominal examination b. Color of the vomitus c. History of constipation d. Presence of high fever e. Resting tachycardia PEER VII Q357

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Question 10 Which of the following is the most common cause of lower gastrointestinal bleeding in school-aged children? a)Anal fissures b)Infectious diarrhea c)Juvenile polyps d)Milk-protein allergy e)Vitamin K deficiency

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Question 11 A 14 year old girl is brought to the emergency department because she has difficulty walking. She has been noted to have some weakness in her legs over the past 36 hours. There is no history of trauma, and she is afebrile. On examination she has normal mental status and normal strength and sensation in her arms. In her lower extremities, she ahs flaccid paralysis, absent reflexes, and no sensation. Which of the following should be done next in the ED? a. Administer an intravenous cephalosporin b. Immediately strap her down to long board c. Initiate fluid resuscitation with 2 L normal saline d. Order MRI of the spine e. Perform lumbar puncture and administer intravenous acyclovir

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Q 11 Answer A 14 year old girl is brought to the emergency department because she has difficulty walking. She has been noted to have some weakness in her legs over the past 36 hours. There is no history of trauma, and she is afebrile. On examination she has normal mental status and normal strength and sensation in her arms. In her lower extremities, she ahs flaccid paralysis, absent reflexes, and no sensation. Which of the following should be done next in the ED? a. Administer an intravenous cephalosporin b. Immediately strap her down to long board c. Initiate fluid resuscitation with 2 L normal saline d. Order MRI of the spine e. Perform lumbar puncture and administer intravenous acyclovir PEER VII Q373

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Question 13 A 4 day old boy presents in shock. According to the mother, he seemed to be doing well until 2 hours prior to presentation. He is cyanotic with mottled skin, has poor tone, and cries weakly. Initial pulse oximetry reading is 78%. After successful intubation and the administration of high-flow oxygen, the pulse oximetry reading remains between 78-82%. Of the following, what is the most appropriate next step? a. Administer intravenous antibiotics and acyclovir b. Call child protective services, and order xrays c. Extubate, suction the airway, and intubate again d. Insert a nasogastric tube to decompress the stomach e. Promptly administer intravenous prostaglandin E1

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Q 13 Answer A 4 day old boy presents in shock. According to the mother, he seemed to be doing well until 2 hours prior to presentation. He is cyanotic with mottled skin, has poor tone, and cries weakly. Initial pulse oximetry reading is 78%. After successful intubation and the administration of high-flow oxygen, the pulse oximetry reading remains between 78-82%. Of the following, what is the most appropriate next step? a. Administer intravenous antibiotics and acyclovir b. Call child protective services, and order xrays c. Extubate, suction the airway, and intubate again d. Insert a nasogastric tube to decompress the stomach e. Promptly administer intravenous prostaglandin E1 PEER VII Q382

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Ductal-Dependent Lesions Ductus arteriosus closes in first 2 weeks of life Babies with congenital heart conditions can depend on a patent ductus arteriosus to perfuse the body will rapidly deteriorate. Babies remain hypoxic despite high flow oxygen Treatment –Prostaglandin E1 –Sepsis workup as well

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Question 14 Which of the following fracture patterns is most likely to be caused by nonaccidental trauma (child abuse) in a 2 year old boy? a. Linear nondepressed parietal skull fracture after falling out of a shopping cart b. Metaphysial corner fracture of the distal tibia after falling out of bed c. minimally displaced supracondylar humerus fracture after falling backwards off a piece of playground equipment d. Torus fracture of the distal radius after falling down three stairs e. Transverse fracture of the middle phalanx of the index finger after the finger was closed in a door by an older sibling

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Q 14 Answer Which of the following fracture patterns is most likely to be caused by nonaccidental trauma (child abuse) in a 2 year old boy? a. Linear nondepressed parietal skull fracture after falling out of a shopping cart b. Metaphysial corner fracture of the distal tibia after falling out of bed c. minimally displaced supracondylar humerus fracture after falling backwards off a piece of playground equipment d. Torus fracture of the distal radius after falling down three stairs e. Transverse fracture of the middle phalanx of the index finger after the finger was closed in a door by an older sibling PEER VI Q59

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Child Abuse - Fractures Metaphyseal “corner” and Triangular “bucket-handle” –Caused by joints being pulled apart forcefully and joint surfaces crushed together and moved back and forth Any fracture can be a sign of child abuse

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Question 15 A 7 year old boy is brought in for evaluation of fever and headache. Examination reveals an acutely ill child with a temperature of 39C (102.2F). A maculopapular rash is present on the wrists, palms, and lower legs. The patient has complained of myalgias, particularly in the lower extremities. Which of the following intravenous agents is most appropriate? a. Acyclovir b. Ampicillin/Sulbactam c. Azithromycin d. Chloramphenicol e. Levofloxacin

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Q 15 Answer A 7 year old boy is brought in for evaluation of fever and headache. Examination reveals an acutely ill child with a temperature of 39C (102.2F). A maculopapular rash is present on the wrists, palms, and lower legs. The patient has complained of myalgias, particularly in the lower extremities. Which of the following intravenous agents is most appropriate? a. Acyclovir b. Ampicillin/Sulbactam c. Azithromycin d. Chloramphenicol e. Levofloxacin PEER VI Q134

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